Provider Demographics
NPI:1427295955
Name:DOMINGUEZ, ROBERTO ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:ALFONSO
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 AVENUE OF CHAMPIONS
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9721
Mailing Address - Country:US
Mailing Address - Phone:859-296-4121
Mailing Address - Fax:859-296-1064
Practice Address - Street 1:40 AVENUE OF CHAMPIONS
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-9721
Practice Address - Country:US
Practice Address - Phone:859-296-4121
Practice Address - Fax:859-296-1064
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY180542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry